HomeMy WebLinkAboutSeptic Pumping Slip - 185 BRIDGES LANE 10/30/2017F5821
Vehicle License Number
Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
ECEIVE:
?O/
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for uselv local Boards Of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The 5ystep, Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of hou e, tLeftl Rtgft iar&ius, Left / right side of house, Left /
Right side of building, Left / Right frOnt of bill ing, Left / Right rear of building, Under deck
Address /
City/Town
2. System Owner.
1-"`-')
State
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type•of system': El Cesspool(s) ErSrePtic Tank
Other (describe):
Date
4. Effluent Tee Filter present? 0 Yes
Condition of System:
2. Quantity Pumped:
Gallons
0 Tight Tank
If yes, was it cleaned? 0 Yes 0 No,
7
6: System Pumped By:
Neil Bateson •
' Name
Bateson Enterprises Inc.
Company
7. Locati9rhere contents were disposed:
Lowell Waste Water
loc. 06/03 System Pumping Record • Page 1 of 1